Clinical competency committee perceptions of entrustable professional activities and their value in assessing fellows: A qualitative study of pediatric subspecialty program directors

A realist synthesis of prospective entrustment decision making by entrustment or clinical competency committees

INTRODUCTION

The real-world mechanisms underlying prospective entrustment decision making (PEDM) by entrustment or clinical competency committees (E/CCCs) are poorly understood. To advance understanding in this area, the authors conducted a realist synthesis of the published literature to address the following research question: In E/CCC efforts to make defensible prospective entrustment decisions (PEDs), what works, for whom, under what circumstances and why?

METHODS

Realist work seeks to understand the contexts (C), mechanisms (M) and outcomes (O) that explain how and why things work (or do not). In the authors' study, contexts included individual E/CCC members, E/CCC structures and processes, and training programmes. The outcome (i.e. desired outcome) was a PED. Mechanisms were a substantial focus of the analysis and informed the core findings. To define a final corpus of 52 included papers, the authors searched four databases, screened all results from those searches and performed a full-text review of a subset of screened papers. Data extraction focused on developing context-mechanism-outcome configurations from the papers, which were used to create a theory for how PEDM leads to PEDs.

RESULTS

PEDM is often driven by default (non-deliberate) decision making rather than a deliberate process of deciding whether a trainee should be entrusted or not. When defaulting, some E/CCCs find red flags that sometimes lead to being more deliberate with decision making. E/CCCs that seek to be deliberate describe PEDM that can be effortful (when data are insufficient or incongruent) or effortless (when data are robust and tell a congruent story about a trainee). Both information about trainee trustworthiness and the sufficiency of data about trainee performance influence PEDM. Several moderators influence what is considered to be sufficient data, how trustworthiness data are viewed and how PEDM is carried out. These include perceived consequences and associated risks, E/CCC member trust propensity, E/CCC member personal knowledge of and experience with trainees and E/CCC structures and processes.

DISCUSSION

PEDM is rarely deliberate but should be. Data about trainee trustworthiness are foundational to making PEDs. Bias, equity and fairness are nearly absent from the papers in this synthesis, and future efforts must seek to advance understanding and practice regarding the roles of bias, equity and fairness in PEDM.

Implementing Entrustable Professional Activities in Pediatric Fellowships: Facilitating the Process

BACKGROUND AND OBJECTIVES

Entrustable professional activities (EPAs) will be used for initial certification by the American Board of Pediatrics by 2028. Less than half of pediatric fellowships currently use EPAs for assessment, yet all will need to adopt them. Our objectives were to identify facilitators and barriers to the implementation of EPAs to assess pediatric fellows and to determine fellowship program directors' (FPD) perceptions of EPAs and Milestones.

METHODS

We conducted a survey of FPDs from 15 pediatric subspecialties. EPA users were asked about their implementation of EPAs, barriers encountered, and perceptions of EPAs. Nonusers were queried about deterrents to using EPAs. Both groups were asked about potential facilitators of implementation and their perceptions of Milestones.

RESULTS

The response rate was 65% (575/883). Of these, 344 (59.8%) were EPA users and 231 (40.2%) were nonusers. Both groups indicated work burden as a barrier to implementation. Nonusers reported more barriers than users (mean [SD]: 7 [3.8] vs 5.8 [3.4], P < .001). Both groups identified training materials and premade assessment forms as facilitators to implementation. Users felt that EPAs were easier to understand than Milestones (89%) and better reflected what it meant to be a practicing subspecialty physician (90%). In contrast, nonusers felt that Milestones were easy to understand (57%) and reflected what it meant to be a practicing subspecialist (58%).

CONCLUSIONS

Implementing EPA-based assessment will require a substantial investment by FPDs, facilitated by guidance and easily accessible resources provided by multiple organizations. Perceived barriers to be addressed include FPD time constraints, a need for additional assessment tools, and outcomes data.

Exploring Factors for Implementation of EPAs in Pediatric Subspecialty Fellowships: A Qualitative Study of Program Directors

OBJECTIVE

To understand fellowship program directors' (FPDs) perspectives on facilitators and barriers to using entrustable professional activities (EPAs) in pediatric subspecialty training.

METHODS

We performed a qualitative study of FPDs, balancing subspecialty, program size, geographic region and current uses of EPAs. A study coordinator conducted 1-on-1 interviews using a semistructured approach to explore EPA use or nonuse and factors supporting or preventing their use. Investigators independently coded transcribed interviews using an inductive approach and the constant comparative method. Group discussion informed code structure development and refinement. Iterative data collection and analysis continued until theoretical sufficiency was achieved, yielding a thematic analysis.

RESULTS

Twenty-eight FPDs representing 11 pediatric subspecialties were interviewed, of whom 16 (57%) reported current EPA use. Five major themes emerged: (1) facilitators including the intuitive nature and simple wording of EPAs; (2) barriers such as workload burden and lack of a regulatory requirement; (2) variable knowledge and training surrounding EPAs, leading to differing levels of understanding; (3) limited current use of EPAs, even among self-reported users; and (4) complementary nature of EPAs and milestones. FPDs acknowledged the differing strengths of both EPAs and milestones but sought additional knowledge about the value added by EPAs for assessing trainees, including the impact on outcomes.

CONCLUSIONS

Identified themes can inform effective and meaningful EPA implementation strategies: Supporting and educating FPDs, ongoing assessment of the value of EPAs in training, and practical integration with current workflow. Generating additional data and engaging stakeholders is critical for successful implementation for the pediatric subspecialties.

Relationship between epa level of supervision with their associated subcompetency milestone levels in pediatric fellow assessment

BACKGROUND

Entrustable Professional Activities (EPA) and competencies represent components of a competency-based education framework. EPAs are assessed based on the level of supervision (LOS) necessary to perform the activity safely and effectively. The broad competencies, broken down into narrower subcompetencies, are assessed using milestones, observable behaviors of one's abilities along a developmental spectrum. Integration of the two methods, accomplished by mapping the most relevant subcompetencies to each EPA, may provide a cross check between the two forms of assessment and uncover those subcompetencies that have the greatest influence on the EPA assessment.

OBJECTIVES

We hypothesized that 1) there would be a strong correlation between EPA LOS ratings with the milestone levels for the subcompetencies mapped to the EPA; 2) some subcompetencies would be more critical in determining entrustment decisions than others, and 3) the correlation would be weaker if the analysis included only milestones reported to the Accreditation Council for Graduate Medical Education (ACGME).

METHODS

In fall 2014 and spring 2015, the Subspecialty Pediatrics Investigator Network asked Clinical Competency Committees to assign milestone levels to each trainee enrolled in a pediatric fellowship for all subcompetencies mapped to 6 Common Pediatric Subspecialty EPAs as well as provide a rating for each EPA based upon a 5-point LOS scale.

RESULTS

One-thousand forty fellows were assessed in fall and 1048 in spring, representing about 27% of all fellows. For each EPA and in both periods, the average milestone level was highly correlated with LOS (rho range 0.59-0.74; p < 0.001). Correlations were similar when using a weighted versus unweighted milestone score or using only the ACGME reported milestones (p > 0.05).

CONCLUSIONS

We found a strong relationship between milestone level and EPA LOS rating but no difference if the subcompetencies were weighted, or if only milestones reported to the ACGME were used. Our results suggest that representative behaviors needed to effectively perform the EPA, such as key subcompetencies and milestones, allow for future language adaptations while still supporting the current model of assessment. In addition, these data provide additional validity evidence for using these complementary tools in building a program of assessment.